Friday, January 1, 2010

Months, Weeks, Days to Live

One of this week's most emailed New York Times article is "Hard Choice for a Comfortable Death: Sedation," which chronicles and details some of the issues encountered by Hospice caregivers, patients, and their loved ones: how does, or can, one die peacefully, comfortably, free from pain, torment, and discomfort - safely, effectively, ethically, and legally?

This question is a familiar one to those of us in the field of Palliative Care. As a Rabbi, Spiritual Counselor, and Spiritual Care Coordinator of The Skirball Hospice, I experience these very questions, every day, with virtually every patient and family. It is, of course, far from easy, with a seemingly unending list of variables and facets. But there remain constants: our primary goal is to keep our patient as pain-free, comfortable, and as safe as possible. One must also remember that our unit of care is not just our patient - we are meant to care for the patient's family, loved ones, and friends.

As a program of the Los Angeles Jewish Home for the Aging, we are Los Angeles' only Jewish Hospice, and our Spiritual Counselors specialize in in facing these issues, and more, from a Jewish perspective. (We, of course, treat patients of every religion, race, and nationality.)

As I previously posted in "All It Takes Is One," human life is of absolute primacy in the Jewish Tradition. Judaism insists that we endeavor to cure with the patient's well-being as our goal, and, traditionally, forbids the hastening of death. At the very same time, we must not prolong the dying process. The codified compendium of Jewish Law, The Shulkhan Arukh, states that, "One in a dying condition is considered living in all respects.” We call this patient, who is typically within 72 hours of death, a Goses (גּוֹסֵס), one who is moribund, unable to swallow; his life is like "a flickering candle." (A Goses exists in a state of gessisah.) It is forbidden to treat the Goses as if he is already dead. It is forbidden to actively hasten his death, as he is alive and this would be considered murder. However, according to Rabbi Isserless’ (16th c., The Rema) gloss on this religious law (his gloss elucidates Ashkenazic Jewish Practice, as it differs from Sephardic custom), it is permissible to remove that which is hindering his death. In the words and time of the text:

It is forbidden to do anything to hasten the death of one who is in a dying condition... If, however, there is something that causes a delay in his death, for example, a nearby woodchopper making noise; or if there is salt on his tongue - and these prevent his speedy death [lit: "delay the soul's leaving the body"] - then one can remove them, because this does not involve any action at all, but rather, is only the removal of the preventative obstacle (to death).[Author's emphasis] [S.A., Y.D. 339:1-2] [Transl. Elliot Dorff, Matters of Life and Death, JPS: Philadelphia (2003) p.199 and Louis E. Newman, "Woodchoppers and Respirators: The Problem of Interpretation in Contemporary Jewish Ethics," Contemporary Jewish Ethics and Morality, A Reader. Oxford University Press: new York (1995. p. 145]

We've been introduced to the legalistic response to impending death. What of the narrative response? We might to turn to the Talmudic tale of "Rabbi Judah's Handmaid:"

On the day that Rabbi Judah [Rabbi Judah Ha Nasi, 2nd C. CE, editor and redactor of The Mishna, the foundational rabbinic text] was dying, the rabbis [his peers and students].... offered a prayer for heavenly mercy [so he would not die]. Rabbi Judah's handmaid, instead, went up to the roof, and prayed [so that he would die]. The rabbis below kept on with their prayers that he might continue to live. From the roof, she took a jar and threw it to the ground below, interrupting their prayers. As they stopped their praying, Rabbi Judah died.[Transl. based upon Louis E. Newman, "Woodchoppers and Respirators: The Problem of Interpretation in Contemporary Jewish Ethics," Contemporary Jewish Ethics and Morality, A Reader. Oxford University Press: new York (1995. p. 141-142.]

The above story was interpreted by Rabbeinu Nissim (11th c. CE), as meaning:

Sometimes one must request mercy on behalf of the ill so that he might die, as in the case of a patient who is terminal and who is in great pain. [Commentary to BT Nedarim 40a; Transl. based upon Louis E. Newman, "Woodchoppers and Respirators: The Problem of Interpretation in Contemporary Jewish Ethics," Contemporary Jewish Ethics and Morality, A Reader. Oxford University Press: new York (1995. p. 142.]

“Do I consider myself a Dr. Death who is bumping people off on a regular basis?... I don’t think so. In my own head I’ve sort of come to the realization that these people deserve to pass comfortably.”

And so we see, in this extremely abbreviated form, Jewish Tradition's different responses to death and dying: As pertaining to Halakha, or Jewish Law, which relies on precedents and analog; theory and general principles; moral intuition, conscience and specific decisions; and the larger societal, and medical influences. [See Aaron L. Mackler, "Cases and Principles in Jewish Bioethics: Toward a Holistic Model," Contemporary Jewish Ethics and Morality, A Reader. Oxford University Press: new York (1995. p. 177-193.]

My Resume at LinkedIn

Who Ami I?

I am a Rabbi... and to make a short story long: I serve Congregation Beth Knesset Bamidbar in Lancaster, California (www.bkb.org) and recently completed eight years as Spiritual Counselor, Spiritual Care Coordinator, and Chaplain for The Skirball Hospice, a Program of the Los Angeles Jewish Home for the Aging.
http://www.linkedin.com/in/rabbi-eric-berk